Health inspection·October 17, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 2 residents who were diagnosed with serious mental disorder, Resident #58. Residents Affected - Few Findings include: Review of Resident #58's admission record with an initial admission date of 10/20/2022 and the most recent admission date of 7/25/2024 revealed Resident #58 had diagnosis of bipolar disorder, with an onset date of 1/6/2020. Review of Resident #58's Level I PASRR screening dated 10/6/2023 showed depressive disorder documented under PASRR Screen Decision-Making section for mental illness. Review of Resident #58's clinical records failed to show documentation Resident #58's diagnosis of bipolar disorder had been included on his Level I PASRR screening dated 10/6/2023. During an interview on 10/16/2024 at 10:04 AM, the Director of Nursing confirmed Resident #58's diagnosis of bipolar disorder had not been included on his Level I PASRR screening dated 10/6/2023. Page 1 of 7 106084 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure residents received treatment and care according to professional standard of practice by administering narcotic pain medication out of parameters for 2 of 3 residents reviewed, Residents #73 and #318. Residents Affected - Few Findings include: 1) Review of Resident #73's physician order dated 10/2/2024 read, Tramadol HCl Oral Tablet 50 mg [milligrams] (Tramadol HCl) Controlled Drug Give 1 tablet via G-Tube [gastrostomy tube] every 8 hours for pain scale 5-10. Review of Resident #73's care plan dated 3/8/2022 read, Focus: [Resident #73's name] has the potential for alteration in comfort related to: limited mobility, general body aches, diabetes . Interventions . Medicate for pain as ordered. Review of Resident #73's Medication Administration Record (MAR) for October 2024 showed the resident received 6:00 AM dose of Tramadol 50 mg on 10/4/2024, 10/5/2024, 10/6/2024, 10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/12/2024 and 10/15/2024 with the pain level documented as zero, and on 10/8/2024 with the pain level documented as NA (not applicable), 2:00 PM dose of Tramadol 50 mg on 10/5/2024, 10/6/2024,10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/13/2024 and 10/14/2024 with the pain level documented as zero, and 10:00 PM dose of Tramadol 50 mg on 10/3/2024, 10/4/2024, 10/5/2024, 10/6/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/11/2024, 10/13/2024, and 10/14/2024 with the pain level documented as zero, and on 10/7/2024 at with the pain level documented as X. 2) Review of Resident #318's physician order dated 10/9/2024 read Hydrocodone- Acetaminophen Oral Tablet 10-325 mg (Hydrocodone-Acetaminophen) Controlled Drug Give 1 tablet by mouth every 8 hours as needed for chronic pain, non-acute 7-10 do not exceed 3000 mg of acetaminophen daily. Review of Resident #318's care plan dated 10/8/2024 read, Focus: [Resident #318's name] has the potential for alteration in comfort related to: general discomfort . Interventions . Medicate for pain as ordered. Review of Resident #318's MAR for October 2024 showed the resident received Hydrocodone-Acetaminophen 10-325 mg on 10/10/2024 at 7:20 AM and 5:22 PM for pain level documented as 5, on 10/11/2024 at 4:56 AM for pain level documented as 5 and at 10:01 PM for pain level documented as 6, on 10/12/2024 at 6:08 AM for pain level documented as 6, on 10/13/2024 at 10:36 AM for pain level documented as 6, and on 10/14/2024 at 9:49 AM for pain level documented as 2. During an interview on 10/15/2024 at 2:35 PM, Staff A, LPN, stated, The medication are to be given when the pain is rated by the patient and the pain rating falls within the parameters. The hydrocodone should not have been given with a pain scale rated less than 7. During an interview on 10/16/2024 at 9:20 AM, Staff B, Licensed Practical Nurse (LPN), stated, Tramadol was administered to the resident out of parameters. If the orders are written with parameters, the medication should only be given if the pain is rated within those parameters. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing stated, Pain medication 106084 Page 2 of 7 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should only be given when pain falls within the parameters that were written by the physician. The physician orders need to be followed. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration revised on 1/1/2022 read, Procedure . 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, included but not limited to the following: 4.1. Facility staff should: 4.1.1 Verify each time a medication is administrated that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. 106084 Page 3 of 7 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2) During an observation on 10/14/2024 at 10:17 AM, Resident #8 was lying in bed watching television. There was one tube of Diclofenac Sodium gel in a plastic bin on the resident's overbed table. During an observation on 10/15/2024 at 8:15 AM, Resident #8 was lying in bed sleeping. There was one tube of Diclofenac Sodium gel in a plastic bin on her overbed table. During an interview on 10/15/2024 at 11:19 AM, Resident #8 stated, I keep the gel there all the time because I use it a lot. Review of Resident #8's physician order dated 10/8/2024 read, [Brand Name of Product] (Diclofenac Sodium) Topical, Apply to affected area topically every day and evening shift for pain. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing stated, It is my expectation that all residents are assessed to be able to self-administer their medications, and if they are able to, then those medications should be kept in a lockbox. Review of the facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals dated 1/11/2024 read, Procedure . 3. General Storage Procedures . 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access . 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/ Prescribed order and approval by the Interdisciplinary Care Team and Facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner in 1 of 3 halls. Findings include: 1) During an observation on 10/14/2024 at 9:30 AM, there were one bottle of zero sugar C gummies and one bottle of red grape seed vitamins on the bedside table in Resident #38's room. During an interview on 10/14/2024 at 10:00 AM, Resident #38 stated, I take my vitamin C and red grape for my circulation daily. During an observation on 10/15/2024 at 11:20 AM, there were one bottle of vitamin C chewable gummies and one bottle of red juice powder pills on the bedside table in Resident #38's room. During an observation on 10/15/2024 at 2:35 PM, with Staff A, Licensed Practical Nurse (LPN), there were one bottle of vitamin C chewable gummies and one bottle of red juice powder pills on the bedside table in Resident #38's room. 106084 Page 4 of 7 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/15/2024 at 2:35 PM, Staff A, LPN, stated, Medications cannot be at the bedside unless the resident has been assessed for self-administration and the medications still need to be secured. During an interview on 10/16/2024 at 11:28 AM, the Director of Nursing (DON) stated, Patients are not to have medication in their room unless they have been assessed for self-administration and the physician writes an order for self-administration and a lockbox is placed in the residents' room so the medication is secured. 106084 Page 5 of 7 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen and reach-in coolers (Photographic evidence obtained). Findings include: During an observation on 10/14/2024 at 9:00 AM, while conducting the initial walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were assorted cut melon and other fruit that were not in the original container without an identifying or date label in the reach-in cooler, two 10-pound rolls of raw ground beef laying on the counter not prepped in a pan or under running water, and uncovered and undated pans containing cake. During an interview on 10/14/2024 at 9:05 AM, the Morning Charge [NAME] stated she should not have placed the dirty rolls of raw ground beef on the counter and the beef should have been in the prep sink with running water. During an interview on 10/14/2024 at 9:07 AM, the CDM verified the unmarked fruit container was in the reach-in cooler without an identifying label or date and confirmed that the raw ground beef should not have been placed on the stainless-steel counter and should have been under running water or prepped and covered and ready to cook. The CDM confirmed the dessert pans of cake should have been covered and dated. Review of the facility policy and procedure titled Food Preparation and Handling revised on 6/1/2019 read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the State and US Food Codes and HACCP [Hazard Analysis & Critical Control Points] guidelines. Procedure . 2. Thawing Foods. A. Thaw meat, poultry and fish in a refrigerator at 41 F or less. b. Foods may also be thawed using the following procedures: i. Completely submerged under running water at a temperature of 70 F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow. Review of the facility policy and procedure titled Food Storage revised on 1/25/2023, read, Procedure . 2. Refrigerators . d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 106084 Page 6 of 7 106084 10/17/2024 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: During an observation on 10/16/2024 at 1:55 PM, Resident #1's room was had a signage on the door that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. The Infection Prevention Officer was applying a wound dressing on Resident #1's lower left leg. The Infection Prevention Officer did not wear a gown during the dressing change for Resident #1. Review of Resident #1's physician order dated 10/15/2024 read, Wound care-left-lower leg: Cleanse open area on left shin with wound cleanser, pat dry, apply xeroform, wrap with [Brand Name of Dressing] dry dressing daily and prn [as needed] for soiled or dislodged dressing. Review of Resident #1's physician order dated 8/22/2024 read, Enhanced Barrier Precautions: Chronic Wound -Indwelling Medical device. Review of Resident #1's care plan dated 4/3/2024 read, Interventions: Enhanced barrier precautions: Wear gown and gloves during resident high-contact activities in room, therapy gym or shower room [i.e. dressing, bathing/showering, transferring, providing hygiene, changing line, toileting/changing briefs, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care]. During an interview on 10/16/2024 at 2:20 PM, the Infection Prevention Officer stated, I didn't use a gown. We need to use gloves and gowns when providing wound care, I forgot. During an interview on 10/16/2024 at 2:28 PM, the Director of Nursing stated, When the residents are on enhanced barrier precautions, the staff must wear a gown and gloves when providing direct wound care. Review of the facility policy and procedure titled Enhanced Barrier Precautions issued on 4/1/2024, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities Policy Explanation and Compliance Guidelines . 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, Wound care: any skin opening requiring a dressing. 106084 Page 7 of 7